Jewish Community of Sedona and the Verde Valley
Religious School Registration Form 2013-2014
Please use a separate form for each child being registered. Please read and fill in both sides completely. All information on this form will be kept confidential and used only by authorized personnel. It is the policy of the JCSVV that all families of registered children are Members of the JCSVV. Please complete the enclosed membership documents and fee schedule for the school. PLEASE PRINT
Student’s Name, Last

Hebrew Name

Student’s Street Address

Student’s Home Phone #


Age on 8-01-13 Gender:
Public School and
M F on 8/01/13
Mother’s Name (or Legal Guardian)

Father’s Name (or Legal Guardian)

Family Email Address
Alternative Email Address, if applicable
Has your child had any previous Jewish education (Religious School, Hebrew School, Jewish Day Camp)? ________________________________________________________________________________ Is there more than one religion observed in your home? ____________________________________________________________________ Does your child have special learning needs? Please explain: _________________________________________________________________ ________________________________________________________________________________ Are you willing to assist during the Religious School year (i.e., make phone calls, participate in your child’s classroom activities, fundraising, host a Family Shabbat Oneg, assist in the Passover Model Seder, contribute time during the Purim carnival and planning of other events)? If yes, which one(s)? _____________________________________________________________ Is there anyone who does NOT have permission to pick up your child? If YES, please list:_________________________________________________________________ PLEASE COMPLETE THE BACK OF THIS SHEET and THE ADDITIONAL PAGE
CONFIDENTIAL MEDICAL INFORMATION for __________________________
Does your child have any allergies (medication, bug bites, food, etc.?) Yes _________________________________________________________________ _________________________________________________________________ Does your child have any physical or emotional conditions of which we should be aware? If YES, please explain: _____________________________________________________________ ________________________________________________________________________________ Does your child have any other special needs? If YES, please list: ________________________________________________________________ ________________________________________________________________________________ EMERGENCY INFORMATION
In case of injury or illness during school, every effort will be made to contact the parent or legal guardian. In case you cannot be reached, please list two people that we may contact in case of an emergency. ____________________________________________________________________________ Name ____________________________________________________________________________ Name If the injury is minor, do you give your permission for us to provide basic first aid? (i.e., bandages, ice packs, etc.) If an injury or illness appears serious, and the parent or guardian cannot to be reached, do you give permission for us to call an ambulance? If your child is feeling ill do we have permission to administer OTC medications? (i.e., Tylenol, Benadryl etc.) (Please attach a detailed description of your child’s health history that should accompany your child in the event an ambulance must be called.) I hereby give authority to any hospital or doctor to render immediate assistance as may be required at the time of an illness or injury to my child. I understand that payment for these services will be my responsibility. ____________________________________

Please list the names and phone numbers of all adults who are permitted to pick up your child from
school without written authorization from you. Please include grandparents, siblings, neighbors,
babysitters and anyone you might ask in an emergency. Only adults over 18 listed below will be
allowed to leave with your child.
Name: ______________________________ Name:_____________________________
Phone:______________________________ Phone:_____________________________
Relationship: _________________________ Relationship: ________________________
JCSVV member? (Y/N)_________________ JCSVV member? (Y/N)_________________
Name: ______________________________ Name:______________________________
Phone:______________________________ Phone:______________________________
Relationship: _________________________ Relationship: _________________________
JCSVV member? (Y/N)_________________ JCSVV member? (Y/N)__________________
Parent Signature: ___________________________________________________
Below please list any special circumstances regarding pick-up that might be important for the
school to know. This includes any information about restrictions about whom we may speak
to concerning your child. If there are restrictions concerning who may pick up your child,
please include this as well. Please include any confidential information on a separate piece of

Source: http://jcsvv.net/PDF/2013-2014%20Religious%20School%20Registration%20Form.pdf


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